Robust laser cutting methods for ophthalmic surgery

ABSTRACT

A method and apparatus for performing ophthalmic laser surgery using a pulsed laser beam is provided. The method includes establishing an initial cutting pattern comprising a plurality of original photodisruption points, establishing an enhanced cutting pattern comprising a plurality of enhanced photodisruption points selected to decrease potential adverse effects due to patient movement and having increased density over a fixed area as compared with the plurality of original photodisruption points, and performing an ocular surgical procedure according to the enhanced cutting pattern Enhanced cutting patterns may include circular cuts around the periphery of a capsule, vertical side cuts for lens fragmentation, raster lamellar cuts, and grid lamellar cuts. Each photodisruption point in the initial cutting pattern and the enhanced cutting pattern comprises a laser target point.

CROSS REFERENCE TO RELATED APPLICATIONS

This application claims priority to and is a divisional of U.S.application Ser. No. 15/851,356, filed on Dec. 21, 2017, now U.S. Pat.No. 10,376,415, which claims priority to and is a divisional of U.S.application Ser. No. 14/157,047, filed on Jan. 16, 2014, now U.S. Pat.No. 9,861,527, which claims the benefit of priority to U.S. ProvisionalApplication No. 61/753,319, filed Jan. 16, 2013, the entire contents ofwhich are incorporated herein by reference.

BACKGROUND I. Field

This invention generally relates to the field of ophthalmic surgery, andmore particularly to particular cutting techniques and methods usedduring ophthalmic laser surgery, including cataract and refractivesurgeries.

II. Background

Vision impairments such as myopia (i.e. near-sightedness), hyperopia(i.e. far-sightedness), and astigmatism can be corrected usingeyeglasses or contact lenses. Alternatively, ophthalmic surgery can beused to address these same problems. Eye surgery is also commonly usedto treat conditions such as cataracts, which, if left untreated, maycause blurred vision and/or blindness.

Laser surgery is becoming a preferred technique for ophthalmicprocedures as a laser is generally more precise and accurate whencompared to manual surgical tools. In laser refractive surgery, such asthe commonly known LASIK (Laser Assisted in Situ Keratomileusis)procedure, a surgeon uses a laser to reshape the cornea. The LASIKprocedure has three steps, namely: (1) preparation of a corneal flap;(2) ablation of the corneal stroma with an excimer laser; and (3)repositioning the flap.

Previously, a microkeratome was used for corneal flap cutting andpreparation, but these days, it is more common to use a non-ultraviolet(UV) laser that emits radiation with ultra-short pulse durations in thefemtosecond or picosecond range. Besides cutting conical flaps, pulsedlasers are also useful for making incisions in the conical stroma tocorrect astigmatism. Ophthalmic lasers provide improvements overmicrokeratomes as more patients achieve an improved level ofpost-operative visual acuity in the months after surgery. Further, lasersurgery tends to lessen the chance of irregular, imprecise, andinaccurate cuts and related complications.

Non-ultraviolet, ultra-short pulsed lasers are also being used forcataract surgery, including capsulotomy procedures. During cataractsurgery, a pulsed laser beam may be used to create an initial incisionin the cornea, to create openings in the anterior or posterior capsularbag for capsulotomy, as well as to crack or break-up the cloudedcataractic lens. For example, a pulsed laser beam can be used to createan opening in the anterior capsule for an anterior capsulotomy procedureto allow access to the cataractic lens. Sometimes, a posteriorcapsulotomy procedure is required after cataract surgery when theposterior capsule becomes cloudy and causes vision problems. Inposterior capsulotomy, the pulsed laser can be used to create an openingin a clouded posterior capsule, thereby allowing light to pass freelythrough the opening. In both types of capsulotomies, pulsed lasersystems reduce the possibility of irregular, inaccurate, and impreciseincisions and related complications that may occur with manual surgicaltechniques.

Laser eye surgeries are generally performed while the patient is awake.Because a patient's eye movement can reduce the procedure's accuracy andprecision, the laser system needs to compensate for and/or reduce orstabilize eye movement. One approach to do so uses an eye stabilizingdevice, such as a patient interface that physically attaches to thepatient's eye and prevents movement. Typically, the patient interface isattached to the eye using mechanical pressure, such as vacuum suction,which can be uncomfortable for the patient, and may even causepost-operative pain and scarring. Thus, certain alternate devices havebeen proposed to compensate for eye movement. These include an eyetracker, which tracks the position of the eye during surgery, andprovides the system with real time signals about eye position. The lasersystem then uses the position information from the eye tracker to adjustor reposition the laser beam before making an incision. To ensureaccuracy and precision, the trajectory of the laser beam's focus must becorrected in real time to compensate for eye movement monitored by theeye tracker. But, there are delays inherent to eye trackers and theirinteractions with the laser system. Because the eye tracker and thelaser beam delivery mechanics tend to introduce positional errors due tolatency between eye movement and laser adjustment, the resultingincision pattern in the eye may deviate from that which is programmed ordesired. These can result in less than ideal incisions.

Therefore, it would be beneficial to provide a pulsed laser surgicalsystem that uses an eye tracker and allows the laser beam to make robustand accurate incisions despite eye tracker/laser beam adjustment latencyissues.

SUMMARY

An objective of this invention is to provide a laser ophthalmic systemthat uses an eye tracker and allows the laser beam to make robust andaccurate incisions despite latency between the eye tracker and laserbeam adjustment, which substantially obviates one or more problems dueto limitations and disadvantages of the related art. To achieve this andother advantages, an embodiment of the present design provides a methodfor performing an ophthalmic laser surgery using a non-ultravioletultra-short pulsed laser system. The method includes establishing aninitial cutting pattern comprising a plurality of originalphotodisruption points, establishing an enhanced cutting patterncomprising a plurality of enhanced photodisruption points selected todecrease potential adverse effects due to patient movement and havingincreased density over a fixed area as compared with the plurality oforiginal photodisruption points, and performing an ocular surgicalprocedure according to the enhanced cutting pattern. Eachphotodisruption point in the initial cutting pattern and the enhancedcutting pattern comprises a laser target point. Examples of cuttingpatterns may include circular cuts around the periphery of a capsule,vertical side cuts for lens fragmentation, raster lamellar cuts, andgrid lamellar cuts. Various aspects and features of the disclosure aredescribed in further detail below.

The above summary and the following detailed description are merelyexemplary, illustrative, and explanatory, and are not intended to limit,but to provide further explanation of the invention as claimed.Additional features and advantages of the invention will be set forth inthe descriptions that follow, and in part, will be apparent from thedescription, or may be learned by practicing various embodiments of theinvention. The objectives and other advantages of the invention will berealized by the structures and methods particularly pointed out in thewritten description and claims as well as the accompanying drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 illustrates a general overview of a pulsed laser systemconfigured to employ an embodiment of the present design.

FIG. 2 is a general diagram including a controller configured to controlvarious components illustrated in FIG. 1.

FIGS. 3A-3C illustrate a first general cutting technique for use in acapsulotomy during laser cataract surgery.

FIGS. 4A and 4B illustrate a second capsulotomy procedure.

FIGS. 5A and 5B illustrate a further embodiment of the present designfor use in performing a vertical side cut.

FIGS. 6A and 6B show a raster lamellar cut pattern.

FIGS. 7A and 7B illustrate an arrangement for performing a lamellar cutfor a corneal flap which is created to expose the corneal stroma inlaser refractive surgery.

DETAILED DESCRIPTION

The following detailed description is merely illustrative and exemplaryin nature and is not intended to limit the embodiments of the subjectmatter or the application, and uses of such embodiments. As used in thisdisclosure, the words “exemplary” and “illustrative” mean “serving as anexample, instance, or illustration.” Any implementation described asexemplary or illustrative is not meant to be necessarily construed aspreferred or advantageous over other implementations. Further, there isno intention to be bound by any expressed or implied theory presented inthe preceding background of the invention, brief summary, or thefollowing detailed description.

FIG. 1 illustrates a general overview of a non-ultraviolet pulsed lasersystem configured to employ an embodiment of the present design. In FIG.1, laser engine 100 includes laser source 101 which provides laser lightin ultra-short pulses to variable attenuator 102 configured to attenuatethe beam, and energy monitors 103 to monitor beam energy level, andfirst safety shutter 104 serving as a shutoff device if the beam isunacceptable. Beam steering mirror 105 redirects the resultant laserbeam to the beam delivery device 110, through articulated arm 106 torange finding camera 111. The range finding camera 111 determines therange needed for the desired focus at the eye 120. Beam delivery device110 includes second safety shutter 112 and beam monitor 113, beampre-expander 114, X-Y (position) scanner 115, and zoom beam expander116. Zoom beam expander 116 expands the beam toward IR mirror 117 whichreflects and transmits the received beam. Mirror 118 reflects thereceived beam to video camera 119, which records the surgical procedureon the eye 120. IR mirror 117 also reflects the laser light energy toobjective lens 121, which focuses the laser light energy to eye 120.

In ophthalmic surgery, a non-ultraviolet (UV), ultra-short pulsed lasercan produce pulsed laser beams having pulse durations measured infemtoseconds. Such a device as shown in FIG. 1 can provide anintrastromal photodisruption technique for reshaping the cornea using anon-UV, ultra-short (e.g., femtosecond or picosecond pulse duration),pulsed laser beam produced by laser source 101 that propagates throughconical tissue and is focused at a point below the surface of the corneato photodisrupt stromal tissue at the focal point. The focusing optics,such as beam pre-expander 114, zoom beam expander 116, IR mirror 117 andobjective lens 121, direct the pulsed laser beam toward an eye 120(e.g., onto or into a cornea) for plasma mediated (e.g., non-UV)photoablation of superficial tissue, or into the stroma of the corneafor intrastromal photodisruption of tissue. In this embodiment, thesystem may also include a lens to change the shape (e.g., flatten orcurve) of the cornea prior to scanning the pulsed laser beam toward theeye. The system is capable of generating the pulsed laser beam withphysical characteristics similar to those of the laser beams generatedby a laser system disclosed in U.S. Pat. Nos. 4,764,930, 5,993,438, orthe like.

The ophthalmic laser system can produce an ultra-short pulsed laser beamfor use as an incising laser beam. This pulsed laser beam preferably haslaser pulses with durations as long as a few nanoseconds or as short asa few femtoseconds. For intrastromal photodisruption of the tissue, thepulsed laser beam has a wavelength that permits the pulsed laser beam topass through the cornea without absorption by the corneal tissue. Thewavelength of the pulsed laser beam is generally in the range of about 3μm to about 1.9 nm, preferably between about 400 nm to about 3000 nm,and the irradiance of the pulsed laser beam for accomplishingphotodisruption of stromal tissues at the focal point is typicallygreater than the threshold for optical breakdown of the tissue. Althougha non-UV, ultrashort pulsed laser beam is described in this embodiment,the pulsed laser beam may have other pulse durations and differentwavelengths in other embodiments. Further examples of devices used inperforming ophthalmic laser surgery are disclosed in, for example, U.S.Pat. Nos. 5,549,632, 5,984,916, and 6,325,792, the contents of each ofwhich are each incorporated herein by reference.

FIG. 2 illustrates a general diagram including a controller configuredto control various components illustrated in FIG. 1. Not shown in FIG. 1is an eye tracker typically used and placed on or adjacent to the eye totrack eye movements. A series of sensors may be provided to sense beamdiameter, location, and intensity at the various mirrors provided. FIG.2 shows a control unit 201 configured to interface with the laser source202 to transmit the laser, the attenuator 203 to attenuate the laserbeam, the first safety shutter 204 to enable shutoff in extremecircumstances, a sensor 205 provided with beam steering mirror 206, andcamera 207. The control unit 201 also interfaces with the x-y scanningdevice 208 to enable x-y scanning of the beam delivery device, andcontrols range finding camera 209, second safety shutter 210, a sensor211 attached to beam monitor 212, the beam pre-expander 213, zoom beamexpander 214, and the sensor 215 attached to IR mirror 216. The controlunit 201 interfaces with video camera 217 and objective lens unit 218which contains the objective lens, and eye tracking system 219.

The present design seeks to control the position of the laser withrespect to the eye and provide patterns and techniques that enable morerobust cuts than previous systems and methods allowed. Certaintechniques using eye tracking systems have been used in the past to makespecific cuts. But, because there is latency between the tracking system219 and the control unit 201 sensing eye movement, and the beam deliverydevice adjusting position of the beam to compensate for such movement,the resulting cuts may be imprecise.

In ophthalmic surgery using a non-ultraviolet, pulsed laser beam, atissue cut is realized when a 2D array of microscopic photodisruptionpoints are connected by the emitted beam, resulting in a macroscopictissue separation. The present design uses an enhanced laser treatmentpattern so that the tolerance for microscopic positional deviations ofphotodisruption points is increased and the likelihood of intendedmacroscopic tissue separation is improved.

Based on an existing pattern of photodisruption points, the presentdesign establishes an enhanced pattern that increases the probabilitythat nearest-neighbor photodisruption points will connect. As part ofthe enhanced pattern, the present design places secondary, backup, orredundant photodisruption points such that multiple connections areavailable between the photodisruption points, thus increasing thelikelihood that sufficient connections exist among the photodisruptionpoints to result in the intended macroscopic tissue separation even inthe presence of positional errors.

The present design includes descriptions of various patterns ofphotodisruption points. However, the design is not specifically limitedto the techniques and patterns disclosed herein. Various other patternsand designs may be used as ocular surgery can change depending on avariety of circumstances and new techniques. In general, however, thespecific patterns employed are intended to provide robust cuts dependingon a number of variables, including the surgical needs, the desired cutshape and orientation, the range of actual and potential positionerrors, the eye movement characteristics, the laser depth of focus, andthe laser pulse rate.

In laser ophthalmic surgery, it is generally understood that virtuallyany laser position can be attained by device and laser beam movement inaddition to the precision focus mechanisms available to the laser. Inthis regard, a number of different patterns and positions can beexecuted or attained. While primarily discussed with respect to makingcertain cuts, it is to be understood the present design may also beemployed to perform fragmentation or chopping of a lens.

FIGS. 3A-3C illustrate a first general cutting technique for use in acapsulotomy during laser cataract surgery. FIG. 3A is a side view of acapsule region desired to be cut, wherein a cut resembling a sine waveis employed around the outside or periphery of the capsule region. InFIG. 3A, the laser scans in the z-direction in a depth range of acertain number of micrometers, i.e. scans up and down an approximatelyequal distance in micrometers around the periphery of the capsule. If apatient moves his or her eye during this procedure, there is apossibility that the cut will not close or complete.

FIG. 3B is a top view of one such scan where patient movement results inthe pattern not being completed, i.e. the end of the pattern does notmeet the beginning of the pattern and thus leaves an uncut gap 301,resulting in incomplete separation and tear of the capsule material.FIG. 3C shows an improved scan according to the present design, whereinthe pattern is altered such that overlap exists, i.e. the side cut isover 360 degrees. In this arrangement, the side cut forms a closed loop.Hence in this embodiment, an initial pattern is contemplated, herehaving a 360 degree profile, and an improved pattern is established,here a greater than 360 degree pattern, going from a revised start point302, cutting according to the pattern, and ending at a revised end point303 resulting in a greater than 360 degree cut. The result is a likelycut with an overlap at or around point 302.

In the drawings, the photodisruption points that are pictured representdesired target points for the laser and not the actual cuts orincisions, which may differ in size and shape and may be slightlyoff-set from the photodisruption points pictured.

Thus the design of FIGS. 3A-3C can be thought of as having onedisruption point as a baseline cut pattern, and a revised or enhancedcut pattern that includes two disruption points, the start and end pointin FIG. 3C, selected to increase the likelihood of a complete cut anddecrease potential adverse effects due to patient movement.

FIGS. 4A and 4B illustrate a second capsulotomy procedure. The top ofFIG. 4A is a side perspective view of the capsule while the bottom ofFIG. 4A is a side view of the capsule. The top view of FIG. 4Aillustrates a series of circles used to cut the capsule in a series ofslices. The bottom view is a side cut-away view illustrating the variousphotodisruption points in the circular pattern. In FIG. 4A, the lasercuts a circle from point 401 to point 402 and back around to point 401,and then proceeds to the next cut. In the presence of position errors,this circular laser cutting trajectory will not return to a pointexactly beneath or above the previous turn, potentially resulting in noconnectivity between turns forming the cut, and therefore, an incompletecut.

FIG. 4B illustrates a spiral pattern for a capsulotomy wherein a seriesof additional photodisruption points are established, in thisarrangement both vertically and horizontally offset from the prior setof photodisruption points, i.e. the baseline pattern of FIG. 4A. Inoperation, a cut is made around the capsule at points 403 and 404, andthe laser proceeds to a cut around the capsule at points 405 and 406,and progresses in this manner via all the remaining points. Thus, thedesign of FIGS. 4A and 4B provide a baseline cut pattern and a modifiedor enhanced cutting pattern including an additional number ofphotodisruption or cut points selected to provide an enhanced likelihoodof tissue separation in the presence of position errors.

FIGS. 5A and 5B illustrate a further embodiment of the present designfor use in a vertical side cut, useful in lens fragmentation andtypically employed during refractive surgery to create a corneal flap.From FIG. 5A, a single layer vertical cut is provided, with a series ofphotodisruption points. As is understood to those skilled in the art,the photodisruption points represent points where the laser is focused,and use of the laser at such photodisruption points causes penetrationof the tissue and adjacent points are in sufficient proximity to preventtearing, i.e. a small enough amount of tissue remains such that thetissue separates and a cut made. In the depiction of FIG. 5A, the laserprogresses sequentially through each of the diagonal lines presented.Again, such a pattern is sensitive to position error in that movement ofthe eye can result in an incomplete or inadequate cut.

FIG. 5B illustrates a multi-layered vertical side cut in accordance withthe present design, wherein additional disruption points are provided atan offset, both vertically and horizontally, from the baseline cutpattern of FIG. 5A. This enhanced multi-layered vertical side cutpattern may be traversed in different ways using the ultra-short pulsedlaser, such as going over and cutting a first (topmost) diagonal line,followed by a cut of a second (lower) diagonal line, and progressingsequentially downward through successive diagonal lines. Thus, thepresent embodiment includes establishing a baseline cut pattern andadding a series of photodisruption points to the baseline profileselected to provide an enhanced likelihood of tissue separation in thepresence of position errors.

FIGS. 6A and 6B illustrate a raster lamellar cut for lens fragmentationaccording to the present design. FIG. 6A shows a baseline raster lasercutting pattern comprising a series of linear cuts to a plurality ofpoints, such as upper point 601 and lower point 602. Such a linearcutting profile is subject to positional errors, possibly resulting inportions of the pattern being uncut, with an increased risk of tearing.The time to complete one raster scan, such as a scan from point 601 to602, is generally less than 10 milliseconds, and this can be enough timeto result in positional errors if the eye moves.

FIG. 6B illustrates a raster scan with two sets of cuts and two sets ofphotodisruption points, including upper first point 603 and upper secondpoint 604, and lower first point 605 and lower second point 606. Thetime to complete one scan, i.e. from upper first point 603 to uppersecond point 604, is typically much less than 10 milliseconds. A briefertraversal of the raster pattern, and a smaller raster pattern used,results in a reduction in the likelihood of position error. Using thepattern of FIG. 6B, the two halves of the raster period(upstroke/downstroke) will more likely connect even in the presence ofeye movement.

For the case of a longer depth of laser focus, which depends on thesystem's numerical aperture, the two raster patterns tend to be thick inthe z-direction, and will be connected when there is an overlap betweenthe two shorter raster patterns shown in FIG. 6B. However, if the depthof focus is small, the system can apply a three dimensional (3D) laserpattern or laser pattern array, shown as pattern 610, to reliablyconnect the two raster patterns to result in big lamellar cut.

From FIG. 6B, it is apparent that the disruption points 604 in the upperraster scan and 605 in the lower raster scan enter, in this view, the 3Dregion, pattern 610. A different sized 3D region, pattern 610 thattouches the end points of a raster scan or raster scans that do nottouch or barely touch the 3D region may be used. In general, overlapbetween the raster scans and the 3D pattern can provided enhancedlikelihood of successful cutting. Thus, the present embodiment comprisesagain establishing a baseline pattern and providing an increased numberof photodisruption points designed or intended to increase likelihood ofa robust cut, or decrease the potential effects of position errors.

FIGS. 7A and 7B illustrate an arrangement for performing a lamellarlaser cut for a flap created to expose the stroma in photoablativerefractive surgery. FIG. 7A shows a regular pattern, here a squarecomprising a series of cut points shown in a Cartesian grid pattern. Inthis case, a non-edge, non-corner photodisruption point has four closestneighbors, and distance between, for example, points diagonal from oneanother is longer than points laterally or vertically separated.Position errors can be an issue with the arrangement of FIG. 7A.

FIG. 7B illustrates a triangular or hexagonal distribution ofphotodisruption points. In FIG. 7B, a triangular cutting pattern ispresented, and use of such a triangular photodisruption point patterneffectively reduces issues related to position errors. Cutting using thetriangular/hexagonal arrangement of FIG. 7B provides a closer proximityof nearest neighbor photodisruption points, decreasing issues ofimproper cuts when the patient moves.

The design of FIGS. 7A and 7B again begin with a baseline pattern ofphotodisruption points and provide an additional quantity ofphotodisruption points intended to decrease positional errors. In thearrangement of FIGS. 7A and 7B, the photodisruption points do notinclude the original pattern with additional photodisruption pointsadded, as in previous embodiments, but instead include an increasednumber of photodisruption points in an equivalent area.

The present design is therefore an apparatus and method for performingophthalmic laser surgery using a pulsed laser beam, wherein the methodcomprises establishing an initial cutting pattern comprising a pluralityof original photodisruption points, and establishing an enhanced cuttingpattern comprising a plurality of enhanced photodisruption points, theplurality of enhanced disruption points selected to decrease potentialadverse effects due to patient movement and having increased densityover a fixed area than the plurality of original photodisruption points.The apparatus or method further includes performing an ocular surgicalprocedure according to the enhanced cutting pattern. Eachphotodisruption point comprises a laser target point. Examples ofcutting patterns may include circular cuts around the periphery of acapsule, vertical side cuts for lens fragmentation, raster lamellarcuts, and grid lamellar cuts.

For example, in the vertical side cut arrangement, the method directsthe pulsed laser beam to make a vertical side cut thereby creating aflap, the vertical side cut traversing a plurality of generally diagonalpaths according to the enhanced fragmentation cutting pattern. Eachphotodisruption point in the initial fragmentation cutting pattern andthe enhanced fragmentation cutting pattern comprises a laser targetpoint, and wherein the vertical side cut traversing the plurality ofgenerally diagonal paths provides an increased length scanning patternrelative to a cut made according to the initial fragmentation cuttingpattern.

Alternately, the present design comprises an apparatus for performing anocular laser surgical procedure based on an initial cutting patterncomprising a plurality of original photodisruption points. The apparatuscomprises a laser system configured to emit a pulsed beam, opticalelements configured to focus the pulsed beam emitted by the laser at adesired position on an eye of a patient, and a controller configured tocontrol the laser and the optical elements, wherein the controller isconfigured to use an enhanced cutting pattern comprising a plurality ofenhanced photodisruption points selected to decrease potential adverseeffects due to patient movement and has increased density over a fixedarea as compared with the plurality of original photodisruption points.Each photodisruption point in the initial cutting pattern and theenhanced cutting pattern comprises a laser target point. Examples ofcutting patterns may again include circular cuts around the periphery ofa capsule, vertical side cuts for lens fragmentation, raster lamellarcuts, and grid lamellar cuts, but other patterns or scans may be used.

In either the method or the apparatus, the plurality of enhancedphotodisruption points may comprise a non-zero percentage of theplurality of original photodisruption points, or the plurality ofenhanced photodisruption points may comprise none of the plurality oforiginal photodisruption points.

An apparatus implementing the techniques or circuits described hereinmay be a stand-alone device or may be part of a larger device or system.In one or more exemplary designs, the functions described may beimplemented in hardware, software, firmware, or any combination thereof.If implemented in software, the functions may be stored on ortransmitted over as one or more instructions or code on acomputer-readable medium. Computer-readable media includes both computerstorage media and communication media including any medium thatfacilitates transfer of a computer program from one place to another. Astorage media may be any available media that can be accessed by acomputer. By way of example, and not limitation, such computer-readablemedia can comprise RAM, ROM, EEPROM, CD-ROM or other optical diskstorage, magnetic disk storage or other magnetic storage devices, or anyother medium that can be used to carry or store desired program code inthe form of instructions or data structures and that can be accessed bya computer. Also, any connection is properly termed a computer-readablemedium. For example, if the software is transmitted from a website,server, or other remote source using a coaxial cable, fiber optic cable,twisted pair, digital subscriber line (DSL), or wireless technologiessuch as infrared, radio, and microwave, then the coaxial cable, fiberoptic cable, twisted pair, DSL, or wireless technologies such asinfrared, radio, and microwave are included in the definition of medium.Disk and disc, as used herein, includes compact disc (CD), laser disc,optical disc, digital versatile disc (DVD), floppy disk and blu-ray discwhere disks usually reproduce data magnetically, while discs reproducedata optically with lasers. Combinations of the above should also beincluded within the scope of computer-readable media.

This disclosure has been provided in an exemplary form with a certaindegree of particularity, and describes the best mode contemplated ofcarrying out the invention to enable a person skilled in the art to makeor use embodiments of the invention. Those skilled in the art willunderstand, however, that various modifications, alternativeconstructions, changes, and variations can be made in the apparatus,method, and parts and steps thereof, without departing from the spiritor scope of the invention. Hence, the disclosure is not intended to belimited to the specific examples and designs that are described. Rather,it should be accorded the broadest scope consistent with the spirit,principles, and novel features disclosed as generally expressed by thefollowing claims and their equivalents.

The invention claimed is:
 1. A method for performing ophthalmic lasersurgery using a device configured to transmit a pulsed laser beam,comprising: establishing an initial fragmentation cutting patterncomprising a plurality of original photodisruption points forming afirst vertical layer extending along a depth direction; establishing anenhanced fragmentation cutting pattern comprising the plurality oforiginal photodisruption points and a plurality of additionalphotodisruption points forming a second vertical layer extending alongthe depth direction, wherein each of the plurality of additionalphotodisruption points is located at an offset from a corresponding oneof the plurality of original photodisruption points both verticallyalong the depth direction and horizontally perpendicular to the depthdirection, wherein the enhanced fragmentation cutting pattern isconfigured to decrease potential adverse effects due to patient movementand having increased density over a fixed area as compared with theplurality of original photodisruption points; and directing the pulsedlaser beam to make a multi-layered vertical side cut thereby creating afragmentation cut, the multi-layered vertical side cut traversing aplurality of generally diagonal paths according to the enhancedfragmentation cutting pattern, the multi-layered vertical side cutincluding the first vertical layer formed of the originalphotodisruption points and the second vertical layer formed of theadditional photodisruption points; wherein each original and additionalphotodisruption point in the enhanced fragmentation cutting patterncomprises a laser target point.
 2. A method for performing ophthalmiclaser surgery using a device configured to transmit a pulsed laser beam,comprising: establishing a cutting pattern comprising a plurality ofphotodisruption points, including a first 2D raster scan pattern, asecond 2D raster scan pattern, and a 3D scan pattern, wherein the first2D raster scan pattern is formed by a set of first photodisruptionpoints, a set of second photodisruption points and a plurality ofadditional photodisruption points between the set of firstphotodisruption points and the set of second photodisruption points, thesecond 2D raster scan pattern is formed by a set of thirdphotodisruption points, a set of fourth photodisruption points andanother plurality of additional photodisruption points between the setof third photodisruption points and the set of fourth photodisruptionpoints, the first and second 2D raster scan patterns extend in a planeparallel to a first direction and are displaced relative to each otheralong the first direction, the 3D scan pattern is a volume formed byphotodisruption points and extends both in the plane and in a seconddirection perpendicular to the plane, and the 3D scan pattern overlapswith the set of second photodisruption points and the set of thirdphotodisruption points; and directing the pulsed laser beam to make araster lamellar cut according to the cutting pattern, wherein the rasterlamellar cut includes two 2D raster regions corresponding to the firstand second 2D raster scan patterns and a 3D laser pattern correspondingto the 3D scan pattern, and wherein the 3D laser pattern is locatedbetween the two 2D raster regions and connects the two 2D raster regionsto form the raster lamellar cut; wherein each photodisruption point inthe cutting pattern comprises a laser target point.
 3. A method forperforming ophthalmic laser surgery using a device configured totransmit a pulsed laser beam, comprising: establishing a cutting patterncomprising a plurality of photodisruption points, wherein the pluralityof photodisruption points form a triangular pattern in which each set ofthree nearest neighboring photodisruption points form an equal-sidedtriangle; and directing the pulsed laser beam to make a lamellar cutaccording to the cutting pattern to produce a flap; wherein eachphotodisruption point in the cutting pattern comprises a laser targetpoint.
 4. An apparatus for performing an ocular laser surgical procedurebased on an initial cutting pattern comprising a plurality of originalphotodisruption points, comprising: a laser configured to emit a beam;optical elements configured to focus the beam emitted by the laser at adesired position on an eye of a patient; and a controller configured tocontrol the laser and the optical elements, wherein the controller isconfigured to control the laser and the optical elements to deliver thelase beam to the eye according to an enhanced cutting pattern, theenhanced cutting pattern comprising the plurality of originalphotodisruption points and a plurality of additional photodisruptionpoints, wherein the plurality of original photodisruption points form afirst vertical layer extending along a depth direction and the pluralityof additional photodisruption points form a second vertical layerextending along the depth direction, wherein each of the plurality ofadditional photodisruption points is located at an offset from acorresponding one of the plurality of original photodisruption pointsboth vertically along the depth direction and horizontally perpendicularto the depth direction, wherein the enhanced fragmentation cuttingpattern is configured to decrease potential adverse effects due topatient movement and has increased density over a fixed area as comparedwith the plurality of original photodisruption points; wherein eachoriginal and additional photodisruption point in the enhanced cuttingpattern comprises a laser target point; and wherein the delivered lasebeam according to the enhanced cutting pattern forms a multi-layeredvertical side cut in the eye of the patient thereby creating afragmentation cut, the multi-layered vertical side cut traversing aplurality of generally diagonal paths, the multi-layered vertical sidecut including the first vertical layer formed of the originalphotodisruption points of the initial fragmentation cutting pattern andthe second vertical layer formed of additional photodisruption points.5. The apparatus of claim 4, wherein the enhanced cutting patternfurther comprises a raster lamellar cut including two 2D raster regionsand a 3D laser pattern, wherein each 2D raster region extends in a planeparallel to a first direction and the two 2D raster regions aredisplaced relative to each other in first direction, and wherein the 3Dlaser pattern is a volume that extends both in the plane and in a seconddirection perpendicular to the plane, and is located between the two 2Draster regions and connects the two 2D raster regions to form the rasterlamellar cut.
 6. The apparatus of claim 4, wherein the enhanced cuttingpattern further comprises a lamellar cut producing a flap, wherein theenhanced photodisruption points form a triangular pattern in which eachset of three nearest neighboring photodisruption points form anequal-sided triangle.